America faces a serious shortage of primary care doctors. The reasons are not hard to understand.
Lower income is the most important factor. Adult primary care doctors (general internal medicine physicians and family medicine physicians) earn on average $100,000 or so less per year than specialists do. Our income is much greater than that of the average American, and so many people have little sympathy here. But almost all people prefer an interesting, challenging, and often difficult job that pays much more to an interesting, challenging, and often difficult job that pays much less.
Helping primary care doctors with medical school debt is unlikely to do much because the amount of debt is overwhelmed by the lifetime income difference. Average debt is around $200,000, and the difference in lifetime earnings is often around $3.5 million. All medical students understand this arithmetic.
The main cause of the income difference is the American Medical Association. This organization, dominated by specialists, essentially sets the relative Medicare rates on which private insurance rates are based. The AMA says that the government sets rates, but this is a ruse. The government follows the AMA’s lead and insurance companies follow the government. The medical establishment has been unable and unwilling to solve the problem, and this situation will continue unless the government takes over the process of setting rates and is willing to displease a large group of doctors to please another group. And the government has to get the numbers right to balance general and specialty care.
Working conditions are less important but do have an effect. Still, cardiologists and orthopedic surgeons work harder than we do, and there is no shortage of medical students interested in these fields. These doctors earn double what we do.
New patterns of care in general medicine have been advocated. The idea is to improve our working conditions by having us work with other health care professionals, like nurse practitioners and physician assistants, to manage patients in the most efficient manner. It is called “working at the top of one’s license.” This will let us keep people healthy, decrease health care costs, and will improve our work days into the bargain. Fewer of us will be needed as others do much of the routine work.
These new patterns of care probably won’t help make the job much better. From what I have seen so far, the idea mostly involves doctors staying later at the office to enter data into computers.
Doctors want to diagnose disease and treat sick people. Those planning to reinvent primary care medicine see things differently. They see us working as a combination of physician, public health officer, clerk, and corporate employee, all for a lot less than we could earn without the last three jobs, if only we were to choose another field.
Would you want to sign up for this, especially if you had other options? Neither do most medical students. If these problems are not addressed, the shortage will worsen. My best guess is that the problem will worsen as decision makers pay lip service to reform but institute no meaningful measures or inadequate half-measures at best.
John Horstkamp is a family physician.
